Anger Management: A Cognitive Behavioral Approach

Presented by

Lance J. Parks, LCSW

Approvals

This course is recognized by the California Board of Behavioral Sciences.

This program is approved for 4 continuing education hours by: The California Board of Registered Nursing # CEP 14462 Texas State Board of Social Worker Examiners # 5547 The National Board for Certified Counselors # 6412 Texas Board of Examiners of Marriage and Family Therapists # 628 Texas State Board of Examiners of Professional Counselors #1646

The National Board for Certified Counselors (NBCC) # 6412

Objectives

1)Define an effective set of strategies for controlling anger. 2)Identify the events that trigger Anger. 3)Identify the four cue categories of anger escalation. 4)State the phases of aggression cycle and explain anger control plans to resolve the cues. 5)Discuss advanced anger management techniques.

INTRODUCTION

This manual was designed for use by qualified substance abuse and mental health clinicians who work with substance abuse and mental health clients with concurrent anger problems. The manual describes a 12-week cognitive behavioral anger management group treatment. Each of the 12 90-minute weekly sessions is described in detail with specific instructions for group leaders, tables and figures that illustrate the key conceptual components of the treatment, and homework assignments for the group participants. An accompanying Participant Workbook is available (see Anger Management for Substance Abuse and Mental Health Clients: Participant Workbook, Reilly, Shopshire, Durazzo, & Campbell, 2002) and should be used in conjunction with this manual to enable the participants to better learn, practice, and integrate the treatment strategies presented in the group sessions. This intervention was developed for studies at the San Francisco Veterans Affairs (SFVA) Medical Center and San Francisco General Hospital.

Cognitive behavioral therapy (CBT) treatments have been found to be effective, time-limited treatments for anger problems (Beck & Fernandez, 1998; Deffenbacher, 1996; Trafate, 1995). Four types of CBT interventions, theoretically unified by principles of social learning theory, are most often used when treating anger disorders:

[Question #1. Which has been found to be an effective, time-limited treatment for anger problems:]

Relaxation interventions, which target emotional and physiological components of anger

Meta-analysis studies (Beck & Fernandez, 1998; Edmondson & Conger, 1996; Trafate, 1995) conclude that there are moderate anger reduction effects for CBT interventions, with average effect sizes ranging from 0.7 to 1.2 (Deffenbacher, 1999). From these studies, it can be inferred that the average participant under CBT conditions fared better than 76 percent of control participants. These results are consistent with other meta-analysis studies examining the effectiveness of CBT interventions in the treatment of depression (Dobson, 1989) and anxiety (Van Balkom et al., 1994).

The treatment model described in this manual is a combined CBT approach that employs relaxation, cognitive, and communication skills interventions.

This combined approach presents the participants with options that draw on these different interventions and then encourages them to develop individualized anger control plans using as many of the techniques as possible. Not all the participants use all the techniques and interventions presented in the treatment (e.g., cognitive restructuring), but almost all finish the treatment with more than one technique or intervention on their anger control plans.

Theoretically, the more techniques and interventions an individual has on his or her anger control plan, the better equipped he or she will be to manage anger in response to angerprovoking events.

In studies at the SFVA Medical Center and San Francisco General Hospital using this treatment model, significant reductions in self-reported anger and violence have consistently been found, as well as decreased substance use (Reilly, Clark, Shopshire, & Delucchi, 1995; Reilly, Shopshire, & Clark, 1999; Reilly & Shopshire, 2000; Shopshire, Reilly, & Ouaou, 1996). Most participants in these studies met Diagnostic and Statistical Manual of Mental Disorders, 4th Edition (DSM-IV) (American Psychiatric Association, 1994) criteria for substance dependence, and many also met DSM-IV criteria for posttraumatic stress disorder. A study comparing Caucasian and African-American patients found that patients from both groups reduced their anger significantly (Clark, Reilly, Shopshire, & Campbell, 1996). Another study showed that women also benefited from the intervention—that is, reported decreased levels of anger (Reilly et al., 1996).

In the anger management studies using this manual, the majority of patients were from ethnic minority groups. Consistent reductions in anger and aggressive behavior occurred in these groups, indicating that anger management group treatment is effective. The treatment model is flexible and can accommodate racial, cultural, and gender issues. The events or situations that trigger someone’s anger may vary somewhat depending on his or her culture or gender. The cues or warning signs of anger may vary in this regard as well. Nevertheless, the overall treatment model still applies and was found effective with different ethnic groups and with both men and women. A person still has to identify the triggering event, recognize the cues to anger, and develop anger management (cognitive behavioral) strategies in response to the event and cues, regardless of whether these events and cues are different for other men and women or for people in other cultural groups.

[Question #3. In the anger management studies the majority of patients were from ethnic minority groups.]

The intervention involves developing individualized anger control plans. For example, some women identified their relationships with their boyfriends or partners or parenting concerns as events that triggered their anger but men rarely identified these issues. Effective individual strategies could be developed, however, to address these issues, provided the women accept the concepts of monitoring anger (using the anger meter) and having (and using) an anger control plan.

This treatment model was also used successfully with non–substance-abusing clients seen in the outpatient SFVA Mental Health Clinic. These clients were diagnosed with a variety of problems, including mood, anxiety, and thought disorders. The treatment components described in this manual served as the core treatment in these studies.

The anger management treatment should be delivered in a group setting. The ideal number of participants in a group is 8, but groups can range from 5 to 10 members. There are several reasons for this recommendation. First, solid empirical support exists for group cognitive behavioral interventions (Carroll, Rounsaville, & Gawin, 1991; Maude-Griffin et al., 1998; Smokowski & Wodarski, 1996); second, group treatment is efficient and cost-effective (Hoyt, 1993; Piper & Joyce, 1996); and third, it provides a greater range of possibilities and flexibility in roleplays (Yalom, 1995) and behavioral rehearsal activities (Heimberg & Juster, 1994; Juster & Heimberg, 1995). Counselors and social workers should have training in cognitive behavioral therapy, group therapy, and substance abuse treatment (preferably, at the master’s level or higher; doctoral-level psychologists have delivered the anger management treatment as well).

[Question #5. In anger management treatment, the ideal number of participants in a group setting is:]

Although a group format is recommended for the anger management treatment, it is possible for qualified clinicians to use this manual in individual sessions with their clients. In this case, the same treatment format and sequence can be used. Individual sessions provide more time for in-depth instruction and individualized behavioral rehearsal.

The anger management treatment manual is designed for adult male and female substance abuse and mental health clients (age 18 years and above). The groups studied at SFVA Medical Center and San Francisco General Hospital have included patients who have used many substances (e.g., cocaine, alcohol, heroin, methamphetamine). These patients have been able to use the anger management materials and benefit from the group treatment despite differences in their primary drug of abuse.

It is recommended that participants be abstinent from drugs and alcohol for at least 2 weeks prior to joining the anger management group. If a participant had a “slip” during his or her enrollment in the group, he or she was not discharged from the group. However, if he or she had repeated slips or a full-blown relapse, the individual was referred to a more intensified treatment setting and asked to start the anger management treatment again.

Many group participants were diagnosed with co-occurring disorders (e.g., posttraumatic stress disorder [PTSD], mood disorder, psychosis) but benefited from the anger management group treatment. Patients were compliant with their psychiatric medication regimen and were monitored by interdisciplinary treatment teams. The San Francisco group found that, if patients were compliant with their medication regimen and abstinent from drugs and alcohol, they could comprehend the treatment material and effectively use concepts such as timeouts and thought stopping to manage anger. However, if a participant had a history of severe mental illness, did not comply with instructions on his or her psychiatric medication regimen, and had difficulty processing the material or accepting group feedback, he or she was referred to his or her psychiatrist for better medication management.

Several practitioners have requested the manual to work with adolescent clients in substance abuse treatment, but no preliminary data from these treatment encounters are available.

Because of the many problems often experienced by substance abuse and mental health clients, this intervention should be used as an adjunctive treatment to substance abuse and mental health treatment. Certain issues, such as anger related to clients’ family of origin and past learning, for example, may best be explored in individual and group therapy outside the anger management group.

Finally, the authors stress the importance of providing ongoing anger management aftercare groups. Participants at the SFVA Medical Center repeatedly asked to attend aftercare groups where they could continue to practice and integrate the anger management strategies they learned in this treatment. At the SFVA Medical Center, both an ongoing drop-in group and a more structured 12-week phase-two group were provided as aftercare components. These groups help participants maintain (and further reduce) the decreased level of anger and aggression they achieved during the initial 12-week anger management group treatment. Participants can also be referred to anger management groups in the community.

It is hoped that this anger management manual will help substance abuse and mental health clinicians provide effective anger management treatment to clients who experience anger problems. Reductions in frequent and intense anger and its destructive consequences can lead to improved physical and mental health of individuals and families.

How To Use This Manual

The information presented in this manual is intended to allow qualified mental health and substance abuse professionals to deliver group cognitive behavioral anger management treatment to clients with substance abuse and mental health disorders. Each of the 12 90-minute weekly sessions is divided into four sections:

Instructions to Group Leaders

Check-In Procedure (beginning in the second session)

Suggested Remarks

Homework Assignments.

The Instructions to Group Leaders section summarizes the information to be presented in the session and outlines the key conceptual components. The Check-In Procedure section provides a structured process by which group members check in at each session and report on the progress of their homework assignments from the previous week. The Suggested Remarks section provides narrative blockeds for the group leader presenting the material in the session. Although the group leader is not required to read the blockeds verbatim, the group leader should deliver the information as closely as possible to the way it is in the blocked. The Homework Assignment section provides instructions for group members on what tasks to review and practice for the next meeting. Session 1 also includes a special section that provides an overview of the anger management treatment and outlines the group rules.

[Question #7. In the 12, 90-minute weekly sessions, the section that provides a structured process by which group members report on the progress of their homework assignments is:]

This manual should be used in conjunction with the Anger Management for Substance Abuse and Mental Health Clients: Participant Workbook (Reilly, Shopshire, Durazzo, & Campbell, 2002). The workbook provides group members with a summary of the information presented in each session, worksheets for completing homework assignments, and space to take notes during each session. The workbook will facilitate the completion of homework assignments and help reinforce the concepts presented over the course of the anger management treatment program.

Although participants are kept busy in each session, 90 minutes should be enough time to complete the tasks at hand. The group leader needs to monitor and, at times, limit the responses of participants, however. This can be done by redirecting them to the question or activity.